telehealth breastfeeding: best practice guideline

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Doctor of Nursing Practice Final Manuscripts Theses and Dissertations

5-22-2021

Telehealth Breastfeeding: Best Practice Guideline Telehealth Breastfeeding: Best Practice Guideline

Laura Amabile University of San Diego, [email protected]

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UNIVERSITY OF SAN DIEGO

Hahn School of Nursing and Health Science

DOCTOR OF NUSRING PRACTICE

Telehealth Breastfeeding: Best Practice Guideline

By

Laura Amabile BSN, RN

A Doctoral of Nursing Practice Portfolio presented to the

FACULTY OF THE HAHN SCHOOL OF NURSING AND HEALTH SCIENCE

BEYSTER INSTITUTE FOR NURSING RESEARCH

UNIVERSITY OF SAN DIEGO

In partial fulfillment of the

requirements for the degree

DOCTOR OF NURSING PRACTICE

May 2021

Kathy James DNSc, FNP, FAAN, Faculty Advisor

ii

Table of Contents

List of Figures ..................................................................................................................... v

Acknowledgments.............................................................................................................. vi

Final Manuscript ................................................................................................................. 1

Abstract ................................................................................................................... 2

Identification of the Clinical Problem ................................................................................. 3

Problem Clarification .............................................................................................. 4

Framework/EBP Model .......................................................................................... 6

Specific Aims .......................................................................................................... 6

Proposed Evidence-Based Solution ........................................................................ 7

Methods................................................................................................................... 8

Participants and Setting................................................................................... 8

Data Collection ............................................................................................... 8

Data Analysis .................................................................................................. 9

Ethical considerations ..................................................................................... 9

Results ..................................................................................................................... 9

Discussion ............................................................................................................. 10

Summary ....................................................................................................... 10

Interpretation ................................................................................................. 11

Cost Benefit Analysis ................................................................................... 11

Limitations .................................................................................................... 13

Conclusion .................................................................................................... 13

iii

Conflicts of Interest............................................................................................... 14

References ............................................................................................................. 15

Appendix A IRB Approval ............................................................................................... 18

Appendix B Letter of Support from Clinical Site ............................................................. 19

Appendix C Poster ............................................................................................................ 20

Appendix D PowerPoint Stakeholder Presentation .......................................................... 21

Appendix E Telehealth Breastfeeding: Best Practice Guideline ...................................... 28

Appendix F Certification .................................................................................................. 36

Appendix G AACN DNP Essentials/NONPF Competencies/ USD DNP Program

Outcomes Exemplars ........................................................................................................ 38

Summary of AACN, NONPF and USD DNP Competencies ............................... 56

DNP Essential I: Scientific Underpinnings for Practice ............................... 56

DNP Essential II: Organizational & System Leadership for Quality

Improvement & Systems Thinking ......................................................... 57

DNP Essential III: Clinical Scholarship & Analytical Methods for Evidence-

Based Practice ......................................................................................... 58

DNP Essential IV: Information Systems/Technology & Patient Care

Technology for Improvement & Transformation of Health Care ........... 58

DNP Essential V: Health Care Policy for Advocacy in Health Care ........... 59

DNP Essential VI: Interprofessional Collaboration for Improving Patient &

Population Health Outcomes ................................................................... 60

DNP Essential VII: Clinical Prevention & Population Health for Improving

Nation’s Health ........................................................................................ 61

iv

DNP Essential VIII: Advanced Nursing Practice ......................................... 61

v

List of Figures

Figure 1 AGREE II Instrument results [Breastfeeding Best Practice Guideline AGREE II

Instrument] .........................................................................................................................16

vi

Acknowledgments

I would like to express my gratitude to the lactation consultants, nurse managers,

and physicians at the Southern California hospital, for supporting me in completing this

evidence-based practice project.

To Dr. Kathy James, my faculty advisor, thank you from the bottom of my heart.

Without your guidance, encouragement and expertise this project would not have been

successful.

Finally, I wish to thank my family for their endless encouragement and love.

Thank you to my parents who have always believed in me and cheered me on to follow

my dreams wherever they led. I love you both. To my caring, loving and supportive

husband, Joseph: my deepest gratitude. Your encouragement in times of stress is much

appreciated and will not be forgotten. In my pursuit of this degree, we became

newlyweds, experienced a pandemic, endured a very long quarantine and incurred several

life changes. Through this journey our marriage has been a source of strength and your

unwavering love a bolster to stand upon.

TELEHEALTH BREASTFEEDING: BEST PRACTICE GUIDELINE 1

Final Manuscript


Laura Amabile

Kathy James

University of San Diego


Abstract

Background: Only 24.9% of United Stated infants are exclusively breastfed

through six months. Healthy People 2020 breastfeeding goals include increasing the

proportion of infant breastfed through six months to 60.6%. The Surgeon General’s Call

to Action identified increasing access to International Board-Certified Lactation

Consultants as a priority to improve breastfeeding percentages.

Purpose: Implementation of an evidence-based telehealth breastfeeding

guideline, will provide mothers with consistent education regarding breastfeeding

practices and guidance to overcome common obstacles, which will then result in

increased confidence levels regarding breastfeeding and increase breastfeeding durations.

Study and Design: The Iowa model was utilized to guide this project. A literature

review of PUBMED and Cochrane databases, the National Institute for Health and Care

Excellence, American Academy of Pediatrics and international lactation consultant

association was performed. Articles included recommendations regarding breastfeeding

hurdles, education, promotion and telehealth.

Methods: The evidence-based research was integrated into a guideline, which

was then evaluated by the AGREE II instrument.

Results: The AGREE II instrument resulted as followed; Scope and Purpose

95.80%, Stakeholder Involvement 98.60%, Rigor of Development 82.80%, Clarity of

Presentation 100%, Applicability 79.20%, Editorial Independence 89.60%, Overall

Quality 95.80% and Recommendation for use 100%.

Key Words: Breastfeeding; Telehealth; Postpartum; Lactation support;

Breastfeeding barriers.



Identification of the Clinical Problem

An estimated 4 million babies are born each year in the United States. Breast milk

provides the essential nutrients required for infant health and development. Breastfeeding

is an integral part of the reproductive process with important implications for the health

of mothers (WHO, 2018). The World Health Organization recommends that all infants be

exclusively breastfed for the first six months of life to achieve optimal growth,

development and health (WHO, 2018). In 2015, 4 out of 5 infants were breastfed initially

at birth (CDC, 2020). This validates that the vast majority of mothers desire to

breastfeeding their infant and attempt to do so. Although the breastfeeding initiation rate

at birth is relatively high, at 83.2%, less then 25% of infants are exclusively breastfeeding

at 6 months (CDC, 2020).

The benefits to breastfeeding are vast. Exclusive breastfeeding reduces child

mortality, promotes sensory and cognitive development, and protects the infant against

infectious as well as chronic diseases (WHO, 2018). Mothers who breastfeed experience

benefits which include reducing the risk of ovarian and breast cancer, increasing family

resources, and providing a secure method for feeding their young (WHO, 2018). The

benefits extend well beyond the initial breastfeeding period. Additionally, it is the

optimal feeding preference for the environment as it decreases waste and pollution

(WHO, 2018).

The Healthy People 2020 breastfeeding goals include increasing the proportion of

infants who are ever breastfed from 74.0% to 81.9%; infants breastfed at 6 months from

43.5% to 60.6% and infants breastfed at 1 year from 22.7% to 34.1% (Healthy People,


2019). Exclusive breastfeeding goals for Health People 2020 included increasing the

proportion of infants who are breastfed exclusively through 3 months from 33.6% to

46.2% and those breastfed exclusively through 6 months from 14.1% to 25.5% (Healthy

People, 2019). Additional goals include reducing the proportion of breastfed newborns

who receive formula supplementation within the first 2 days of life from 24.2% to 14.2%

(Healthy People, 2019).

Problem Clarification

Overall, there has been an increase in breastfeeding rates over the last decade, yet

there are numerous complex barriers that are experienced by new mothers attempting to

breastfeed and racial disparities still persist (CDC, 2020). Lack of knowledge regarding

breastfeeding continues to be one of the most significant barriers for all mothers.

Breastfeeding is often portrayed as “natural” but in truth it is a process in which both the

new mother and infant have to become skilled at. Skills such as achieving a deep latch,

positioning and breast care need to be learned. Mothers tend to expect breastfeeding to

come effortlessly and therefore become frustrated easily. It is also important to note that

breastfeeding rates noticeably vary in regard to race/ethnicity, mothers age, and education

level, participation in WIC, and the ratio of family income to the federal poverty

threshold (CDC, 2020). There are multiple factors influencing a woman’s decision on

whether or not to initiate and sustain breastfeeding (CDC, 2020).

The lack of knowledge and support continue to be two of the largest barriers

experienced by mothers attempting to breastfeeding exclusively. This is

disproportionately to mothers of the lower income. These individuals report inadequate

breastfeeding information receival from providers and lack of access to professional


breastfeeding support (CDC, 2020). Furthermore, most common reasons mothers

discontinue breastfeeding are due to factors such as breast pain, soreness, and infection

(30%), nipple shields (25%), latch and positioning (24%), milk supply and production

(17%), and the use of breast pumps (17%) (Kapinos et al., 2019). The Surgeon Generals

Call to Action to Support Breastfeeding identified increasing access to International

Board-Certified Lactation Consults (IBCLC’s) as a priority to improve breastfeeding

duration and exclusivity (Kapinos et al., 2019).

Support from International Board-Certified Lactation Consults (IBCLCs) is

associated with longer breastfeeding durations and exclusivity (Uscher Pines et al., 2019).

Lactation consultant provided telehealth breastfeeding support provides mothers with the

support and knowledge needed to successfully breastfeed their infant. Breastfeeding

telehealth visits provide access to valuable breastfeeding support to those who otherwise

are not be able to access lactation care. Telehealth breastfeeding support promotes

exclusive breastfeeding and/or maintenance of breastfeeding as well as decreases the

probability of discontinuing breastfeeding (Santos, Borges, Zocche, 2020). IBCLCS are

well positioned to address breastfeeding obstacles that other providers such as

pediatricians may not be able to due to limited training and competing time demands

(Uscher Pines et al., 2019). Telehealth breastfeeding support has been found to have an

overall satisfaction rating of 94% with participants reporting telehealth visits as simple

and convenient (Santos et al., 2020). Telehealth breastfeeding has increased exclusive

breastfeeding duration/maintenance and decreased probability of breastfeeding by those

who participate (Santos et al., 2020).


Framework/EBP Model

The Iowa Model is a highly recognized guide for health care providers to apply

research findings to improve patient care (Titler et al., 2001). The Iowa model serves as a

7-step process to identify an opportunity for practice improvement and to institute a

practice change (Melnyk & Fineout-Overholt, 2019). Since there is currently a lack of

telehealth breastfeeding guidelines to be utilized by lactation consultants, this model

serves as a framework for designing an evidence-based practice guideline, instituting

such guideline and disseminating its results. The feedback loops utilized in this model are

vital to the success of this project. Since there is no current telehealth breastfeeding

guideline available the dissemination of this project could be of service to all medical

professionals seeking to provide telehealth breastfeeding support.

Specific Aims

The purpose of this Evidence Based Project was to create a guideline for lactation

consultants to utilize during telehealth breastfeeding visits to improve the patients

breastfeeding experience and support breastfeeding continuation. Current telehealth

breastfeeding services provided by lactation consultants at this current location were

limited and no current guideline existed for these encounters. Lactation consultants

expressed the desire for a guideline to aid their current practice by providing consistent

breastfeeding education, recommendations, and encouragement from one provider to the

next. Lactation consultants expressed apprehension toward providing telehealth visits and

it was the hope that the creation of a guideline would promote confidence. An additional

goal of the guideline was to promote all staff discharging patients from the postpartum

unit to provide patients with information regarding telehealth lactation services and


encourage they utilize the resource. Following the development of the guideline, the

AGREE II instrument was used by the lactation consultants to evaluate the acceptance

level of the guideline and its potential recommendations for use.

Facilitators of this project included support from the nursing managers and

lactation consultants on the mother baby unit at this specific hospital. Barriers included

staff resistance, lactation consultant buy in and ineffective communication. The aims of

increasing the percentages of infants exclusively breastfed and IBCLC’s comfort is

providing telehealth care are noteworthy reasons to complete the project.

Proposed Evidence-Based Solution

In order to create the telehealth breastfeeding best practice guideline; Cochrane

and PUBMED databases were searched through August to October 2020 for articles

published in the last 10 years using terms such as lactation support, postpartum,

breastfeeding, breastfeeding promotion, and telelactation. A wider search was expanded

to the National Institute for Health and Care Excellence searching for specific

breastfeeding guidelines. The American Academy of Pediatrics and International

Lactation Consultant Association were also searched for relevant guidelines. Articles

were incorporated only if they included recommendations for overcoming common

breastfeeding hurdles, breastfeeding education, breastfeeding promotion or telehealth

breastfeeding recommendations. Articles had to have cited evidence and reference lists

available through the internet in full text English. A total of 13 articles were chosen to

provide the evidence based breastfeeding recommendations and interventions based on

their overall quality of evidence. Each source of evidence was categorized using the John

Hopkin’s Appendix D Evidence Level and Quality Guide.


Relevant research was taken into account to develop a telehealth breastfeeding

guideline to be utilized by International Board-Certified Lactation Consultants. The

guideline concentrates on managing breastfeeding mothers most frequently reported

obstacles and difficulties. The evidence-based recommendations were integrated into the

breastfeeding telehealth guideline to aid in providing patients with accurate and

consistent information.

Methods

Participants and Setting

The Institutional Review Board deemed the project exempt from IRB approval as

it is secondary research for which consent is not required. The support of the nursing

manager and obstetric provider on the Mother Baby unit at the hospital in Southern

California were both obtained prior to the start of this project. Additionally, buy in from

the Lactation Consultants at the hospital in Southern California was obtained.

Data Collection

Following collection of the evidence based breastfeeding recommendations the

initial draft was created by the project creator. The initial draft of the guideline was

distributed to the lactation team via email. A virtual meeting was held on December 15th,

2020 to review the guideline, answer questions and receive criticism. All lactation

consultants were able to provide feedback and proposals for modifications. Amendments

to the initial guideline were made and the final guideline was distributed on December

21st, 2020 to the lactation team through email. With the final breastfeeding telehealth

guideline, all team members received an AGREE II Instrument to evaluate the created

guideline with. Results from the AGREE II instrument were collected by January 10th


20201. Results of the survey were analyzed and prepared for distribution January 11th-

16th 2021.

Data Analysis

Of the six lactation consultants, four completed the AGREE II instrument.

Microsoft Excel was used to compute the quality score for each of the six AGREE II

domains. The AGREE II instrument consists of 23 key items which are organized into six

domains and two global rating items for overall assessment. The six domains are as

follows: Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of

Presentation, Applicability, and Editorial Independence. Each domain is rated on a scale

from 1-7, 1 being strongly disagree and 7 being strongly agree. The six domain scores

remained independent and were not aggregated into a single quality score. The domain

scores were used to determine if the guideline should be recommended for use or not.

Dissemination of the results from the AGREE II Instrument and telehealth

breastfeeding best practice guideline was provided on February 16th, 2021 via

videoconference meeting with the lactation consultant team and maternal child health

nurse managers of the hospital.

Ethical considerations

Ethical aspects of implementing were addressed. Neither patient information nor

patient contact was required. An ethics review was performed and considered exempt.

There were no conflicts of interest identified.

Results

The DNP student analyzed each domain of the AGREE II instrument to

accurately calculate the scaled domain scores. As seen in table 1, the pattern of domain


scores differentiated the telehealth breastfeeding best practice guideline as a high-quality

guideline. The findings regarding the overall guideline quality and its recommendation

for use provide positive influence for implementing guideline at this particular hospital in

Southern California. It also bears significant weight in its potential usage in additional

settings across this hospital system and medical practices across the country.

Table 1

Breastfeeding Best Practice Guideline: AGREE II Instrument

Discussion

Summary

Implementing telehealth best practice breastfeeding guideline was 100%

recommended for use by lactation consultants at this specific Hospital. The guideline

provides a framework for care provided supporting mothers breastfeeding knowledge,

confidence and skills to successfully sustain breastfeeding. Breastfeeding positively

impacts the health of mothers, infants, the environment and economy.

95.80% 98.60%

82.80%

100%

79.20%89.60%

95.80% 100%

Breastfeeding Best Practice GuidelineAGREE II Instrument


Interpretation

The creation of the evidence based breastfeeding guideline will support lactation

consultants in providing accurate and consistent information regarding breastfeeding

practices. It will promote consistent care which focuses on helping mothers understand

the importance of breastfeeding and how to overcome obstacles that might prevent them

from continuing breastfeeding

Cost Benefit Analysis

The project experienced minimal cost. The total cost was $480. This cost included

the expense of two one-hour assessment and education sessions for six lactation

consultants at $40/hour. There were no additional costs experienced for this project.

The United State Lactation Consultant Association compiled the excessive

medical costs non breastfeeding mothers and infants experience and the potential health

care savings that could be seen from supporting breastfeeding for all mothers. It was

discovered that there was an excessive costs of office visits, hospitalizations and

medications in non-breastfed infants compared to breastfed infants which totaled $5,909

per child per year (Gutowski et al, 2014). Therefore, it was stated that the cost benefit of

exclusively breastfeeding for the first six months and continued breastfeeding for one

year would be $5,909 per child per year (Gutowski et al, 2014). Data evaluation of

medical costs had determined that if 90% of United States families followed medical

recommendations of breastfeeding exclusively for the first 6 months of life and then

continuing for one year, $13 billion could be saved and 911 infant deaths prevented

annually (Gutowski et al, 2014).


The cost saving of breastfed infants was found as a result from the risk reductions

of childhood illnesses. The risk reduction percentages were found to be the following;

100% reduction in acute otitis media, 47% reduction in atopic dermatitis, 178% reduction

in gastrointestinal infections, 275% reduction in lower respiratory infection,

hospitalization rate, 67% reduction in asthma, with family history, 35% reduction in

asthma without family history, 32% reduction in childhood obesity, 64% reduction in

type II diabetes, 13% reduction in acute lymphocytic leukemia, 18% reduction in acute

myelogenous leukemia, 56% reduction in sudden infant death syndrome and 138%

reduction in necrotizing enterocolitis in preterm infants (Gutowski et al, 2014). Infants

who are breastfed experience a reduction in health risks across their lifetime and those

who are not breastfed or are breastfed for only a short period are exposed to a higher

disease risk not only as infants and children but also as adults (Gutowski et al, 2014).

The excessive medical costs for mothers were identified as $9,715 per individual

(Gutowski et al, 2014).The overall cost benefit yield for women who breastfed was found

to be $18.265 billion based off 2011 projections (Gutowski et al, 2014).The risk

reduction for women who breastfeed were found to be as followed; 12% reduction in

diabetes, 8.4% reduction in metabolic syndrome, 21% reduction in ovarian cancer, 4.3%

reduction in breast cancer, 23% reduction in coronary artery disease, 22% reduction in

aortic calcifications and 15% reduction in coronary calcifications (Gutowski et al, 2014).

The cost savings for one mother and one infant couplet who adhere to the

recommendations to breastfeed exclusively for six months and continue for one year

would yield $15,624. There would continue to be a $5,909 saving per child per year. In

this particular project for every dollar spent, there is a $32.55 cost savings. The return on


investment is projected to be 3,155%. The non-financial benefits to this project include

patient appreciation and empowerment, improved communication with patients and

families, and improved patient confidence regarding breastfeeding obstacles and

continuation.

Limitations

Limits to the generalizability of the work include possible need for language

translation. Given the nature of the work there were very few factors that limited internal

validity. Those who completed the AGREE II instrument were able to submit their

responses anonymously in an effort to minimize limitations. The team of lactation

consultants at this particular location was small and therefore lead to a limited sample

size of guideline analysis.

Conclusion

The telehealth breastfeeding guideline was 100% recommended for use by the

board-certified lactation consultants. The guideline will be implemented at this specific

location with the oversight by the nursing manager of the postpartum unit. The guideline

will be proposed to the other applicable locations which are attempting telehealth

breastfeeding support within the hospital network. The board-certified lactation

consultants will sustain the guideline with the assistance from nursing managers. There

is a potential to spread this guideline further to any medical facility wanting or already

attempting telehealth breastfeeding support. This would be incredibly applicable to rural

settings. Further study would include the direct impact this guideline provides to

breastfeeding initiation and sustenance. Additionally, the impact of mother’s confidence,

knowledge and attitude to breastfeeding practices would be of interest.


Conflicts of Interest

The author has no conflict of interest.

Acknowledgments

This work was supported by the University of San Diego and the hospital in

southern California.


References

American Academy of Pediatrics. (2021, May). Breastfeeding overview. Retrieved from

https://services.aap.org/en/patient-care/breastfeeding/breastfeeding-

overview/Center for Disease Control and Prevention. (2020, September 17).

Breastfeeding report card.

Retrieved October 29, 2020, from https://www.cdc.gov/breastfeeding/data/reportcard.htm

Center for Disease Control and Prevention. (2020, January 22). Proper Storage and

Preparation of Breast Milk. Retrieved November 23, 2020, from

https://bit.ly/2dxVYLU

Gutowski JL, Walker M, Chetwynd E.: “Containing Health Care Costs Help in Plain

Sight. International Board-Certified Lactation Consultants: Allied Healthcare

Providers

Contribute to the Solution. 3rd Edition” Washington, D.C. United States Lactation

Consultant Association, July 2014.

Kapinos, K., Kotzias, V., Bogen, D., Ray, K., Demirci, J., Rigas, M. A., & Uscher-Pines,

L. (2019). The Use of and Experiences with Telelactation Among Rural

Breastfeeding Mothers: Secondary Analysis of a Randomized Controlled

Trial. Journal of Medical Internet Research, 21(9). doi:10.2196/13967

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing &

healthcare: A guide to best practice. Philadelphia: Wolters Kluwer.

National Institute for Health and Care Excellence. (2015, February 1). Overview:

Postnatal care up to 8 weeks after birth: Guidance. NICE.

https://www.nice.org.uk/guidance/cg37.


Office of the Surgeon General (US), Centers for Disease Control and Prevention, &

Office on Women's Health. (2011). A Call to Action: The Surgeon General's Call

to Action to Support Breastfeeding. Retrieved November 23, 2020, from

https://www.ncbi.nlm.nih.gov/books/NBK52691/

Santos, L. F., Borges, R. F., & Azambuja, D. A. (2020). Telehealth and Breastfeeding:

An Integrative Review. Telemedicine and E-Health, 26(7), 837-846.

doi:10.1089/tmj.2019.0073

Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., …

Goode, C. J. (2001). The Iowa Model of Evidence-Based Practice to Promote

Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497–509.

doi: 10.1016/s0899-5885(18)30017-0

Uscher-Pines, L., Ghosh-Dastidar, B., Bogen, D. L., Ray, K. N., Demirci, J. R., Mehrotra,

A., & Kapinos, K. A. (2020). Feasibility and Effectiveness of Telelactation

Among Rural Breastfeeding Women. Academic Pediatrics, 20(5), 652-

659.doi:10.1016/j.acap.2019.10.008

Westerfield, K., Koenig, K., & Oh, R. (2018). Breastfeeding: Common Questions and

Answers. American Academy of Family Physicians. doi:https://www-aafp-

org.sandiego.idm.oclc.org/afp/2018/0915/p368.html

World Health Organization. (2018, January 1). Guideline: Counselling of women to

improve breastfeeding practices. Retrieved October 29, 2020, from

https://www.who.int/publications/i/item/9789241550468


World Health Organization. (2020, August 24). Infant and young child feeding. Retrieved

November 23, 2020, from https://www.who.int/news-room/fact-

sheets/detail/infant-and-young-child-feeding

18

Appendix A

IRB Approval

19

Appendix B

Letter of Support from Clinical Site

20

Appendix C

Poster

21

Appendix D

PowerPoint Stakeholder Presentation


Laura Amabile, BSN, RN

DNP Student

University of San Diego

Kathy James DNSc FNP FAAN

22

Problem statement:

Current breastfeeding rates fail to meet the healthy people 2020 goals. Woman lack breastfeeding knowledge and confidence needed to initiate and sustain breastfeeding.

Overarching Project Goal:

By implementing a telehealth breastfeeding guideline, we can provide consistent education to mothers regarding breastfeeding practices and guidance to overcome common obstacles, which will result in increased confidence regarding breastfeeding and increase breastfeeding durations.

Driving Forces for Project

For Lactation Consultants at Scripps Mercy Chula Vista Mother

Baby Unit, what is the level of acceptance of an evidence based

breastfeeding guideline using the AGREE II instrument.

PICO(T) Question

23

Framework/EBP Model

§ The Iowa model was used to guide this project. The model provides a step by step guide to identify issues, research solutions and implement change.

24

Project Implementation Timeline

§ Implementation December 15, 2020

§ Date Auditing for December 20, 2020

§ Completion January 1, 2021

25

Results/Outcomes

95.80% 98.60%

82.80%

100%

79.20%

89.60%95.80%

100%

SCOPE A

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OVER

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REC

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DATIO

N F

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SE

Breastfeeding Best Practice Guideline

AGREE II Instument

Formulas:

CBA = $15,624 = $ 32.55

$ 480

For every dollar spent, there is a $32.55 cost savings.

ROI = $15,624 - $480 x 100 = 3,155% ROI

$480

Cost-Benefit & ROI

26

• Increased breastfeeding initiation and duration.

• Increased patient satisfaction.

• Decreased negative health consequences for infants, including sudden infant death syndrome, obesity, necrotizing enterocolitis, respiratory infections and type 2 diabetes.

• Decreased negative health consequences for women including diabetes, breast and ovarian cancers.

• Decreased number of unnecessary office visits.

• Project will be sustained through lactation consultantsand nursing managers

Expected Implications for Clinical Practice & Sustainability

Implementing the telehealth best practice breastfeeding guideline was 100% recommended for use by lactation consultants at Scripps Mercy Chula Vista Hospital. The guideline provides a framework for supporting mothers breastfeeding knowledge, confidence and skills to successfully sustain breastfeeding. Breastfeeding positively impacts the health of mothers, infants, the environment and economy.

Conclusion

27

Poster

28

Appendix E


I. PURPOSE a. To promote breastfeeding duration and exclusivity and provide the support

mothers need to breastfeed their infants. 3 b. To promote a system to guarantee continuity of skilled support for lactation

between hospital and health care settings.3 c. To promote a philosophy in maternal-infant care which advocates and

supports breastfeeding as the optimal form of infant feeding. d. To provide breastfeeding families accurate and consistent information in

accordance with the WHO/UNICEF, the American Academy of Family physicians, and CDC.

e. To assist breastfeeding families with the continuation of exclusive breastfeeding by providing a positive maternal-infant environment that is maximally conducive for breastfeeding success.

f. To provide new and current Maternal Child Health (MCH) staff with the education and procedures for successful telehealth breastfeeding support.

II. PERSONNEL a. International Board-Certified Lactation Consultants (IBCLC’s) b. Registered Nurses c. Physicians, Certified Nurse Midwives, Nurse Practitioners

III. EQUIPMENT a. Computer with webcam b. Internet c. Breast Pump d. Nipple Shield e. Lanolin f. hydrogels g. Additional teaching tools such as breast model, stomach size capacity visuals

etc.

IV. RECOMMENDATION a. IBCLC’s will provide mothers with telehealth breastfeeding support visit after

hospital discharge. b. IBCLC’s and registered nurses will educate and encourage mothers prior to

hospital discharge on how to contact the lactation line after discharge to schedule a telehealth visit with a lactation consultant.

c. Mothers experiencing breastfeeding difficulties during their hospital stay or mothers who are likely to discontinue breastfeeding should be encouraged to schedule telehealth lactation consultation 2 days after discharge or sooner.

29

d. EDUCATION OF BENEFITS OF BREASTFEEDING i. Mothers should be encouraged to breastfeed exclusively for the first

6 months of life with continued breastfeeding up to 2 years of age or beyond.5

ii. Mothers should be educated regarding the health benefits of breastfeeding as they relate to both mother and infant

1. MATERNAL HEALTH BENEFITS a. Decrease risk of breast and ovarian cancer,

hypertension, type 2 diabetes mellitus, and postpartum depression.4

2. INFANT HEALTH BENEFITS a. Decrease risk of atopic dermatitis and intestinal

gastroenteritis.4 b. Higher IQ later in life.4 c. Decrease risk of childhood leukemia, hypertension,

necrotizing enterocolitis, obesity, otitis media, respiratory illnesses such as asthma, severe lower respiratory infections, sudden infant death syndrome and type 1 and 2 diabetes.4

e. ASSESSING BREASTFEEDING i. Unrestricted breastfeeding frequency and duration should be

encouraged.2 ii. Women should be advised on indications of proper infant latch,

positioning and feeding.2 iii. Women should be given information about available breastfeeding

support groups. iv. Patient breastfeeding experience should be addressed at each visit to

assess if she is on course with effective breastfeeding and to identify need for additional intervention. Breastfeeding progression should be addressed and documented at each visit.2

f. BREASTFEEDING CONCERNS i. INSUFFICIENT MILK SUPPLY

1. If insufficient milk is perceived by the patient, attachment and positioning should be reviewed and her infant’s health evaluated. Reassurance should be offered to support the patient to gain confidence in her ability to produce enough milk.2

2. Infant weight should be monitored through weight testing and infant output.4

3. Patient should be instructed to weigh infant with clothes on before and after feeding. IBCLC’s will then subtract the pre-

30

feeding weight from the post feeding weight. One gram of weight is estimated to be the equivalent of 1ml of milk intake.4

4. IBCLC’s will assess feeding, pumping and infant stooling and voiding patterns during each visit.

5. Mothers should be educated regarding recommended milk intake, voiding pattern and stooling patterns for breastfeeding infants.4

a. 6 or more voids should be expected in a 24-hour period. 4

b. 0-24 hours – intake 2-10ml per feeding, 1 stool a day which is dark green to black and sticky.4

c. 24-48 hours – intake 5-15ml per feeding, 2 stools a day which are dark green to black and stick.4

d. 48-72 hours – 15-30 ml per feeding – 6-8 stools per day which are green.4

e. 72-96 hours – 30 t0 60 ml per feeding, 6-8 stools per day which are green.4

f. >5 days 60-120 ml per feeding, 6-8 stools per day which are light mustard-seed yellow.4

6. If infant is not taking sufficient milk from the breast directly and supplementation is necessary, expressed milk should be offered first by cup or bottle.2

7. Additional finger feeding, spoon feeding, and French feeding tube should be utilized as seen appropriate by IBCLC

8. For medically necessary formula supplementation, the academy of breastfeeding medicine protocol for supplementation will be used.4

ii. NIPPLE PAIN 1. Patients should be advised that nipples often become painful

or cracked due to improper latching.2 2. Infant latch and positioning should be evaluated for signs of

good positioning and latch each visit. 3. Signs of good positioning and latch will be assessed and

discussed with patient a. Infant nose is free from the breast (also referenced as

sniffing position).4 b. Infants chin in pressed against the breast.4 c. Infants cheeks are rounded, no sunken in or dimpled d. Infants mouth is open wide like a yawn.4 e. If any areola is visible, more is seen above the infant’s

top lip, with little to none showing near the chin.4 f. Infants lower lip is flanged outward.4

31

g. Infants body is in line with the head and facing towards the mother “tummy to tummy”.4

h. Feeding is not painful to the mother after the initial 30 seconds to one minute after latching.4

i. Infant has a rhythmic suck and swallow pattern.4 iii. NIPPLE DAMAGE

1. Lactation consultant will aid in the adjustment of latch and infant position or pump flange size to stop trauma to the nipple.4

2. Patient should be encouraged to apply expressed breast milk to the nipple after feedings and as needed in between feedings. 4

3. Patient education provided should include lanolin, all-purpose nipple ointment, breast shells, and glycerin pads which can be used but are no more effective than expressed breast milk. Hydrogel dressings should be encouraged as they manage pain more effectively than lanolin. 4

iv. BLOCKED MILK DUCTS 1. Patient should be encouraged to massage area of tender

nodule or apply vibration. 4 2. Patient should be educated regarding avoiding constricting

clothing, increasing frequency of feedings or pumping, hand expression focusing on area for complete emptying. 4

3. Patient should be educated regarding dangle feeding, heat therapy, and rest and hydration.4

v. MASTITIS 1. Patients should be educated regarding the signs and

symptoms of mastitis, including flu like symptoms, tender, red, and painful breast.2

2. Patients with symptoms of mastitis should be counseled on infant positioning and latch.2

3. Patient should be encouraged to continue breastfeeding and hand expression for effective milk expression and if symptoms continue more than a few hours the patient should schedule an urgent appointment with primary care provider.2

vi. ENGORGEMENT 1. Patient education should be provided that breast may become

tender, painful and firm around day 3 of life for infant as it at this time that the milk “comes in”.2

2. Patients should be educated to wear well-fitting bras that do not compress breast.2

3. Engorgement of the breasts should be treated with unrestricted breastfeeding, breast massage, hand expression,

32

hot or cold packs, application of cabbage leaves and analgesia as needed.2

4. Lactation consultant should provide education regarding reverse pressure softening, feeding infant in reclined position.

4 vii. MILK BLEBS

1. Patient encouraged to soak the breast in warm saltwater for 5-10 minutes and gently rub the nipple with soft cloth to abrade and unroof blister. If ineffective patient should be encouraged to make appointment with primary care provider.

4 viii. INVERTED NIPPLES

1. Patients with inverted nipples should receive additional support and care to ensure successful breastfeeding.2

ix. NIPPLE SHIELD 1. Lactation consultants will assess the underlying reason which

cause the mother to initially use the nipple shield and offer the appropriate education and support. 4

2. The lactation consultant will assess at each visit the need for continued use of the nipple shield and refer the patient to pediatrician if referrals are needed to remedy the situation. 4

x. EXPRESSION AND STORAGE 1. Mothers will receive education regarding breast pump use,

milk storage and preparation in accordance with the CDC recommendations. CDC recommendations can be noted at the end of guideline.5

33

(CDC,2020)

34

(CDC,2020)

Always thaw the oldest milk first .

Thaw m ilk under lukew arm running w ater, in

a cont ainer o f lukew arm w ater, o r overnight in

t he ref r igerato r.

Never t haw or heat m ilk in a m icrow ave.

Microw aving dest roys nut r ient s and creates hot

spot s, w hich can burn a bab y ’s m out h.

Wash d isassem b led pum p and feed ing part s in

a clean basin w it h soap and w ater. Do not wash

directly in t he sink because t he germ s in t he sink

could cont am inate it em s.

Rinse t horoughly under running w ater. A ir-d ry

it em s on a c lean d ishtow el o r paper t owel.

Using c lean hands, st ore d ry it em s in a c lean,

p ro tected area.

W hen freezing leave an inch of space at the top

of the container; breast milk expands as it freezes.

Milk can be stored in an insulated cooler bag

w ith frozen ice packs for up to 24 hours when

you are t raveling.

If you don’t p lan t o use freshly expressed milk

within 4 days, freeze it right away.

Use m ilk within 24 hours of t haw ing in t he

ref r igerat or ( f rom t he t im e it is com p let ely t haw ed ,

not f rom t he t im e w hen y ou t ook it out o f t he f reezer) .

Use t hawed m ilk within 2 hours

o f b r ing ing t o room tem perat ure

or w arm ing .

Never refreeze thawed milk.

FOR MORE INFORMATION, VISIT:https:/ / bit .ly/ 2dxVYLU

Test t he t em perat ure before feed ing it t o your

baby by put t ing a few d rops on your w rist .

It should f eel w arm , not hot.

Sw ir l t he m ilk t o m ix t he fat , w hich m ay

have separated .

If your baby d id not f inish t he bot t le, lef t over

m ilk should be used within 2 hours.

Milk can be served cold, room temperature,

or warm.

To heat m ilk, p lace t he sealed cont ainer

into a bow l o f w arm w ater or ho ld

under w arm running w ater.

Do not heat m ilk d irect ly on t he

st ove or in t he m icrow ave.

For extra germ removal, sanit ize feeding items

daily using one of these methods:

• clean in the d ishwasher using hot w ater and heated drying cycle (or sanit ize set t ing).

• boil in w ater for 5 minut es (aft er cleaning).

• steam in a microwave or p lug-in steam system according to the manufacturer ’s d irect ions (aft er cleaning).

296657-B

Label milk w ith the da te it w as expressed and

the child ’s name if delivering t o childcare.

Freeze milk in small amounts of 2

to 4 ounces to avoid wast ing any.

Store milk in the back of the fr eezer or

refrigerator, not the door.

STORE

FEED

THAW

CLEAN

June 20 19

35

References

1. Center for Disease Control and Prevention. (2020, January 22). Proper Storage

and Preparation of Breast Milk. Retrieved November 23, 2020, from

https://bit.ly/2dxVYLU

2. National Institute for Health and Care Excellence. (2015, February 15). 1

Recommendations: Postnatal care up to 8 weeks after birth: Guidance. Retrieved

November 23, 2020, from https://www.nice.org.uk/guidance/cg37/chapter/1-

Recommendations

3. Office of the Surgeon General (US), Centers for Disease Control and Prevention,

& Office on Women's Health. (2011). A Call to Action The Surgeon General's

Call to Action to Support Breastfeeding. Retrieved November 23, 2020, from

https://www.ncbi.nlm.nih.gov/books/NBK52691/

4. Westerfield, K., Koenig, K., & Oh, R. (2018). Breastfeeding: Common Questions

and Answers. American Academy of Family Physicians. doi:https://www-aafp-

org.sandiego.idm.oclc.org/afp/2018/0915/p368.html

5. World Health Organization. (2020, August 24). Infant and young child feeding.

Retrieved November 23, 2020, from https://www.who.int/news-room/fact-

sheets/detail/infant-and-young-child-feeding

36

Appendix F

Certification

38

Appendix G

AACN DNP Essentials/NONPF Competencies/

USD DNP Program Outcomes Exemplars

AACN DNP Essentials & NONPF

Competencies

USD DNP Program Objectives Exemplars

Provide bulleted exemplars that

demonstrates achievement of each

objective

DNP Essential I: Scientific

Underpinnings for Practice

NONPF: Scientific Foundation

Competencies

The scientific foundation of nursing

practice has expanded and includes a

focus on both the natural and social

sciences including human biology,

genomics, science of therapeutics,

psychosocial sciences, as well as the

science of complex organizational

structures. In addition, philosophical,

ethical, and historical issues inherent in

the development of science create a

context for the application of the natural

and social sciences.

2. Synthesize nursing and other scientific

and ethical theories and concepts to create

a foundation for advanced nursing

practice.

Fall 2018

• Integrated nursing theories into

analysis of current research in

practice, developed PICO

statement in methods of

translational Science (DNPC

611).

• Conducted literature reviews

related to breastfeeding and

evidence-based practice

recommendations (DNPC 611).

Summer 2019

• Critically examined the character

and constitutions of advanced

nursing practice and practice

inquiry (DNPC 610).

• Critically evaluated the literature

regarding the development of

reflective practice (DNPC 610).

39


Competencies




objective

• Analyzed the relationships

between philosophical stance,

practice perspectives, and

inquiry/research methodologies

(DNPC 610).

Fall 2019

• Synthesized knowledge of

advanced pathogenesis and clinical

genetics as a basis for evaluation

of patients with multi-system

disease states (DNPC 622).

• Evaluated subjective and objective

clinical findings to formulate

differential diagnoses for patients

with complex disease states

(DNPC 622).

• Explored current therapies and

investigational interventions

including pharmacogenetics for

complex disease states in the

acutely or chronically ill

individual utilizing evidence-

based practice models (DNPC

622).

40


Competencies




objective

Spring 2020

• Evaluated relevant developmental,

behavioral and sociocultural

concepts in assessing the health

care needs of individuals and their

families (NPTC 604).

• Differentiated appropriate

screening techniques to identify

and manage individuals at risk

for common acute and chronic

health problems (NPTC 604).

• Utilized pathophysiological

concepts to develop differentials

and working diagnosis in the

evaluation of individuals

with common acute and chronic

health problems (NPTC 604).

• Delineated the Iowa model

underlying a specific prenatal

breastfeeding education program

(DNPC 686).

Fall 2020

• Conducted literature reviews

related to breastfeeding and

evidence-based practice

41


Competencies




objective

recommendations for telehealth

(DNPC 630).

• Critically evaluated literature

regarding the telehealth

breastfeeding evidence-based

practice (DNPC 630).


underlying a specific telehealth

breastfeeding guideline (DNPC

630).

DNP Essential II: Organizational &

System Leadership for Quality

improvement and Systems Thinking

NONPF: Leadership

Competencies/Health Delivery System

Competencies

Advanced nursing practice includes an

organizational and systems leadership

component that emphasizes practice,

ongoing improvement of health outcomes,

and ensuring patient safety. Nurses should

be prepared with sophisticated expertise

in assessing organizations, identifying

system’s issues, and facilitating

organization-wide changes in practice

5. Design, implement, and evaluate ethical

health care delivery systems and

information systems that meet societal

needs and ensure accountability for

quality outcomes.

Fall 2018

• Identified and evaluated the need

for breastfeeding promotion and

supportive care in primary care

clinics.

• Analyzed current research

regarding successful breastfeeding

promotion programs and

implementation.

Spring 2019

• Analyzed the health care

environment of breastfeeding

practice setting, prepared a

strategic plan appropriate for the

environment, developed

implementation steps for

42


Competencies




objective

delivery. This also requires political skills,

systems thinking, and the business and

financial acumen needed for the analysis

of the practice quality and costs.

increasing breastfeeding rates and

accomplishing the strategic plan

(DNPC 626).

• Participated in needs assessments

of breastfeeding market and in the

design of programs (10 steps to

breastfeeding), products, and

services to meet lactation needs

(DNPC 626).

Summer 2019

• Applied principles of program

planning to the design of an

evidence-based practice project

and health care delivery

educational program (DNPC 686).

• Summarized the evidence base for

a specific prenatal breastfeeding

education program (DNPC 686).

• Utilized scientific evidence as a

basis for designing practice

changes and outcomes (DNPC

686).


underlying the specific program

(DNPC 686).

Fall 2019

43


Competencies




objective

• Demonstrate an understanding of

and practice within an ethical

framework and the legal

requirements for clinical practice

as a nurse practitioner (NPTC

602).

Spring 2020

• Developed and implement plans of

care in collaboration with

individuals and their families that

integrate developmental,

psychosocial, spiritual, and

physiological needs (NPTC 604).

• Analyzed the role and economic

impact of the nurse practitioner in

a collaborative interdisciplinary

model of care (NPTC 604).

• Demonstrated understanding of





604).

• Developed an evaluated plan for a

specific prenatal breastfeeding

44


Competencies




objective

education program with an

emphasis on sustainability (DNPC

686).

• Formulated a plan for effective

dissemination of evaluation results

to appropriate stakeholders (DNPC

686).

Fall 2020

• Identified and evaluated the need

for a telehealth breastfeeding

guideline for lactation consultants

in the hospital setting.

• Analyzed current research

regarding successful telehealth

breastfeeding promotion

• Formulated a plan guideline

evaluation using the AGREE II

instrument and a plan for the

dissemination of evaluation results

to appropriate stakeholders (DNPC

630).

Spring 2021

• Implemented telehealth

breastfeeding best practice

guideline in the hospital setting

(DNPC 630).

45


Competencies




objective

DNP Essential III: Clinical Scholarship

& Analytical Methods for Evidence-

Based Practice

NONPF: Quality

Competencies/Practice Inquiry

Competencies

Scholarship and research are the

hallmarks of doctoral education. Although

basic research is viewed as the first and

most essential form of scholarly activity,

an enlarged perspective of scholarship

has emerged through alternative

paradigms that involve more than

discovery of new knowledge. These

paradigms recognize: (2) the scholarship

of discovery and integration “reflects the

investigative and synthesizing traditions

of academic life;” (2) scholars give

meaning to isolated facts and making

connections across disciplines through the

scholarship of integration; and (3) the

scholar applies knowledge to solve a

problem via the scholarship of application

that involves the translation of research

4. Incorporate research into practice

through critical appraisal of existing

evidence, evaluating practice outcomes,

and developing evidence-based practice

guidelines.

Fall 2018

• Conducted a systematic review of

current practice guidelines

regarding breastfeeding (DNPC

611).

• Developed implementation plan

regarding breastfeeding promotion

and clinical care practices (DNPC

611).

Spring 2019

• Expanded literature review

regarding barriers experienced by

postpartum women when

breastfeeding (DNPC 626).

• Expanded literature review of

current practice guidelines in

promotion of breastfeeding during

the prenatal and postpartum period

(DNPC 626).

Fall 2019

• Evaluated the effectiveness of

evidence-based strategies to

promote and maintain the health of

individuals and families across the

lifespan (NPTC 602).

46


Competencies




objective

into practice and dissemination and

integration of new knowledge.

Spring 2020

• Summarized the evidence base for

a specific project to increase

breastfeeding initiation and

duration through a prenatal

breastfeeding program (DNPC

686).

• Utilized scientific evidence as a

basis for designing practice

changes and outcomes (DNPC

686).

DNP Essential IV: Information

Systems/Technology & Patient Care

Technology for Improvement &

Transformation of Health Care

NONPF: Technology & Information

Literacy Competencies

DNP graduates are distinguished by their

abilities to use information

systems/technology to support and

improve patient care and health care

systems, and provide leadership within

health care systems and/or academic

settings. Knowledge and skills related to

information systems/technology and

7. Incorporate ethical regulatory, and legal

guidelines in the delivery of health care

and the selection, use, and evaluation of

information systems and patient care

technology.

Spring 2019

• Began in the collection of

exclusive breastfeeding rates and

compiled data into chart for

analysis (HCI 540).

• Compared and contrast various

technology and data resources

needed for retrieving, storing,

analyzing, managing, and

communicating information for the

delivery of nursing and health care

(HCI 540).

• Used spreadsheets, statistical and

database applications to support

clinical and management decision-

47


Competencies




objective

patient care technology prepare the DNP

graduates apply new knowledge, manage

individual and aggregate level

information, and assess the efficacy of

patient care technology appropriate to a

specialized area of practice along with the

design, selection, and use of information

systems/technology to evaluate programs

of care, outcomes of care, and care

systems. Information systems/technology

provide a mechanism to apply budget and

productivity tools, practice information

systems and decision supports, and web-

based learning or intervention tools to

support and improve patient care.

making and outcomes

management in the clinical and

health care management setting

(HCI 540).

• Critiqued software applications

and existing health care

information systems for their

utility and their appropriateness to

support health care practice (HCI

540).

Spring 2020

• Utilized technology and systematic

reviews of clinical research as a

basis for evidence-based practice

(NPTC 604).

• Fall 2020

• Obtained Biomedical Research

Human Certification –

Basic/Refresher Course through

CITI (DNPC630).

• Obtained USD IRB approval for

DNP EBP project.

• Implementation of DNP project in

hospital care setting utilizing

telehealth breastfeeding best

practice guideline.

48


Competencies




objective

DNP Essential V: Health Care Policy

for Advocacy in Health Care

NONPF: Policy Competencies

Health care policy, whether created

through governmental actions,

institutional decision-making, or

organizational standards, creates a

framework that can facilitate or impede

the delivery of health care services or the

ability of the provider to engage in

practice to address health care needs.

Engagement in the process of policy

development is central to creating a

health care system that meets the needs of

its constituents. Political activism and the

commitment to policy development are

central elements of DNP practice.

3. Demonstrate leadership in collaborative

efforts to develop and implement policies

to improve health care delivery and

outcomes at all levels of professional

practice (institutional, local, state,

regional, national, and/or international).

Spring 2019

• Conducted a policy analysis

related to a health care delivery

issue using a theoretical

framework (DNP 648).

• Developed and critiqued strategies

for promoting nursing involvement

in policy development (DNP 648).

• Examined the impact of legal and

regulatory issues on health care

delivery and advanced nursing

practice roles (DNP 648).

• Addressed policy brief to

American Nursing Association

regarding implementation of

mental health screenings changes

that could aid in decreasing the

homeless veteran population and

vulnerability military members

(APNC 523).

• Addressed the American College

of Obstetricians and Gynecologists

on furthering the education of

primary care providers relating to

breastfeeding practices to combat

the astronomically low

49


Competencies




objective

breastfeeding rates across the

nation (APNC 523).

• Addressed congress regarding

short term disability insurance to

permit mothers to take maternity

leave in hopes of increasing

breastfeeding rates (APNC 523).

• Use advanced communication

skills and processes to lead quality

improvement and in aim to meet

the healthy people 2020

breastfeeding goals (APNC 523).

Spring 2021

• Presented telehealth breastfeeding

best practice guideline to lactation

team and nursing managers

(DNPC630).

• Became a student member of the

American Association of Nurse

Practitioners. DNP Essential VI: Interprofessional

Collaboration for Improving Patient &

Population Health Outcomes

NONPF: Leadership Competencies

1. Demonstrate advanced levels of clinical

practice within defined ethical, legal, and

regulatory parameters in designing,

implementing, and evaluating evidenced-

based, culturally competent therapeutic

Spring 2019

• Began the process of collaboration

with University of San Diego

Mentors in regard to EBP project

50


Competencies




objective

Today’s complex, multi-tiered health care

environment depends on the contributions

of highly skilled and knowledgeable

individuals from multiple professions. In

order to accomplish the IOM mandate for

safe, timely, effective, efficient, equitable,

and patient-centered care in this

environment, health care professionals

must function as highly collaborative

teams. DNPs have advanced preparation

in the interprofessional dimension of

health care that enable them to facilitate

collaborative team functioning and

overcome impediments to

interprofessional practice. DNP

graduates have preparation in methods of

effective team leadership and are

prepared to play a central role in

establishing interprofessional teams,

participating in the work of the team, and

assuming leadership of the team when

appropriate.

interventions for individuals or

aggregates.

3. Demonstrate leadership in collaborative

efforts to develop and implement policies

to improve health care delivery and out

comes at all levels of professional practice

(institutional, local, state, regional,

national, and/or international).

Summer 2019

• Proposed a business plan to

implement a new business idea

(DNPC 653).

• Developed an executive summary

of a business plan for a healthcare

service (DNPC 653).

• Explored fundamental financial

management knowledge, skills and

analytic techniques in various

health care settings (DNPC 653).

Fall 2019

• Obtained complete and accurate

comprehensive and problem-

focused histories, modifying

interviewing techniques as

appropriate based on age,

development, culture and

cognition capacity (APNC 521).

• Integrated developmentally and

culturally appropriate advanced

examination techniques to

systematically obtain an expanded

physical assessment database

(APNC 521).

51


Competencies




objective

• Formulated appropriate

differential diagnoses from an

expanded physical assessment

database (APNC 521).

• Demonstrated understanding of

ethical and legal requirements for

APRN clinical practice (APNC

521).

Summer 2020

• Differentiated non-emergent from

emergent conditions and initiate

interprofessional treatment,

consultation, and referral (NPTC

605/608).

• Analyzed the role and economic

impact of the nurse practitioner in

a collaborative interdisciplinary

model of care (NPTC 605/608).

• Demonstratec understanding of





605/608).

52


Competencies




objective

Fall 2020

• Shared evidence-based literature

with clinicians in hospital setting

indicating need for EBP project

• Proposed telehealth breastfeeding

guideline project to nurse

managers, obstrectic providers and

lactation consultants (DNPC 630).

• Submitted EBP project for

telehealth breastfeeding guidleline

project to USD IRB (DNPC 630).

• Selected EBP journals to submit

final EBP project (DNPC 630).

Spring 2021

• Implemented DNP EBP project in

the hospital setting in

collaboration with lactation

consultants and nursing managers.

DNP Essential VII: Clinical Prevention

& Population Health for Improving

Nation’s Health

NONPF: Leadership Competencies

Consistent with national calls for action

and with the longstanding focus on health

6. Employ a population health focus in the

design, implementation, and evaluation of

health care delivery systems that address

primary secondary, and tertiary levels of

prevention.

Spring 2019

• Began design of EBP in prenatal

and postpartum breastfeeding

promotion and support groups.

• Compared and contrasted various

technology and data resources

needed for retrieving, storing,

analyzing, managing, and

53


Competencies




objective

promotion and disease prevention in

nursing, the DNP graduate has a

foundation in clinical prevention and

population health. This foundation

enables DNP graduates to analyze

epidemiological, biostatistical,

occupational, and environmental data in

the development, implementation, and

evaluation of clinical prevention and

population.

communicating information for the

delivery of nursing and health care

(HCIN 540).

Summer 2019

• Used scientific foundation and

processes of inquiry to evaluate

the evidence base related to a

clinical problem (DNP 630).

• Provided leadership in system

change required for solution of a

clinical problem (DNP 630).

• Demonstrated advanced clinical

competencies in the area of

maternity and newborn care (DNP

630).

Spring 2020

• Applied principles of program

planning to the design of a

prenatal breastfeeding evidence-

based practice project (DNPC

686).

Summer 2020/Spring 2021

• Evaluated relevant developmental,

behavioral and sociocultural

concepts in assessing the health

54


Competencies




objective

care needs of individuals and their

families (NPTC 605/608/609).

• Differentiated appropropriate

screening techniques to identify

and manage individuals at risk for

common chronic and acute health

problems (NPTC 605/608/609).

• Develop and implement plans of

care in collaboration with

individuals and their families that

integrate developmental, psychosocial, spiritual, and physiological needs (NPTC 605/608/609).

DNP Essential VIII: Advanced Nursing

Practice

NONPF: Independent Practice/Ethics

Competencies

The increased knowledge and

sophistication of health care has resulted

in the growth of specialization in nursing

in order to ensure competence in these

highly complex areas of practice. The

reality of the growth of specialization in

1. Demonstrate advanced levels of clinical

practice within defined ethical, legal, and

regulatory parameters in designing,

implementing, and evaluating evidence-

based, culturally competent therapeutic

interventions for individuals or

aggregates.

Spring 2019

• Demonstrated knowledge of

California Pharmacy Board rules

and regulations, California Health

& Safety Codes, and the Federal

Register (APNC 523).

• Examined the furnishing of drugs

and/or devices pursuant to the

California BRN practice

requirements, standardized

procedures, and in conformance

55


Competencies




objective

nursing practice is that no individual can

master all advanced roles and the

requisite knowledge for enacting these

roles. DNP programs provide preparation

within distinct specialties that require

expertise, advanced knowledge, and

mastery in one are of nursing practice. A

DNP graduate is prepared to practice in

an area of specialization within the larger

domain of nursing.

with applicable laws, codes, and/or

regulations (APNC 523).

• Analyze approaches to the

development, monitoring, and

modification of the therapeutic

regimen based on an evaluation of

individual patient characteristics

and responses to treatment (APNC

523).

• Identify appropriate client-related

information about

furnished/prescribed drugs and/or

devices (APNC 523).

Spring 2020

• Demonstrated understanding of and

practice within an ethical framework

and the legal requirements for clinical

practice as a nurse practitioner (NPTC

604).

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Summary of AACN, NONPF and USD DNP Competencies

DNP Essential I: Scientific Underpinnings for Practice

Objective 2: Synthesize nursing and other scientific and ethical theories and

concepts to create a foundation for advanced nursing practice.

Throughout the doctoral program I have learned the pathophysiological and

pharmacological concepts for competent evaluation and management of acute and

chronic health conditions across the lifespan. I have expanded my knowledge of

pathogenesis of complex disease states and learned how pharmacogenetics and

pharmacogenomics could enhance my prescription for patient medications. I have learned

the importance of the scientific foundation of nursing practice which includes a focus on

both the natural and social sciences including biology, genomics, science of therapeutics,

psychosocial sciences, as well as the science of complex organizational structures. In

addition, throughout the program I have learned about philosophical, ethical, and

historical issues which create a context for application of natural and social sciences. In

my final year, I implemented the DNP project, Telehealth Breastfeeding: Best Practice

Guideline highlighting the importance of evidence based clinical practice, quality

improvement and support for rural communities. Through these experiences, I have

become knowledgeable on how to incorporate ethical concepts, scientific knowledge, and

complex management to provide all encompassing patient care.

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DNP Essential II: Organizational & System Leadership for Quality Improvement &

Systems Thinking

Objective 5: Design, implement, and evaluate ethical health care delivery systems and

information systems that meet societal needs and ensure accountability for quality

outcomes.

While achieving this degree, I have learned that the advanced nursing practice

includes an organizational and systemic leadership component that emphasizes evidence-

based practice, quality improvement and the ongoing improvement of health outcomes.

In my first year I was given a hypothetical DNP project proposal and chose the topic

which addressed the homeless veteran population with a specific look at mental health. In

the second year I chose a topic which addressed discrepancies in low-income

breastfeeding percentages. In my final year, during the troubling time of the covid 19

pandemic, I identified a need for telehealth breastfeeding support. This became my DNP

project. I presented my proposal to stakeholders, developed a systematic approach,

performed a literature review and created an evidence-based telehealth breastfeeding

guideline. I presented to key stakeholders who then evaluated the guideline using the

AGREE II instrument and 100% recommended it for use. The knowledge and experience

I have gained will enable me to successfully and effectively develop solutions to

problems that arise in my future practice.

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DNP Essential III: Clinical Scholarship & Analytical Methods for Evidence-Based

Practice

Objective 4: Incorporate research into practice through critical appraisal of

existing evidence, evaluating practice outcomes, and developing evidence-based

practice guidelines.

In the pursuit of higher education, I have learned that scholarship and research are

the hallmarks of the doctoral education. The mainstay of the doctoral nursing degree is

the incorporation of evidence-based research into practice. In my first year, I conducted

systematic reviews and implemented plans regarding health promotion and clinical care

practices. I collaborated with peers to create a comprehensive assessment of stickler

syndrome’s pathogenesis. I presented it for discussion and dissemination of information

to my classmates. Through my work on my DNP project, I reviewed and evaluated

literature to create an evidence-based practice guideline for implementation. I was

successful in completing my EBP project because of the extensive knowledge base I had

acquired during my program’s progression. I feel confident in my knowledge to solve a

problem and influence patient care though the incorporation of research into practice.

DNP Essential IV: Information Systems/Technology & Patient Care Technology for

Improvement & Transformation of Health Care

Objective 7: Incorporate ethical, regulatory, and legal guidelines in the

delivery of health care and the selection, use, and evaluation of information systems

and patient care technology.

In the first year of my program, the course Healthcare Informatics provided me

with a instruments and knowledge required for information systems and technology to

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support and improve patient care. I have extensive experience navigating online resources

and electronic health records. I have compared and contrasted various technology and

data resources needed for retrieving, storing, analyzing, managing and communication

information for the delivery of health care. Additionally, given the circumstances of the

Covid 19 pandemic I was able to utilize the technologies of telehealth to provide

exceptional and easier to access to care. For my DNP project, I utilized technology and

systematic reviews for clinical research as a basis for evidence-based practice and utilized

technology to present my project highlighting key points of success. The knowledge

obtained in relation to technology will enrich my future practice.

DNP Essential V: Health Care Policy for Advocacy in Health Care

Objective 3: Demonstrate leadership in collaborative efforts to develop and

implement policies to improve health care delivery and outcomes at all levels of

professional practice.

The DNP program fostered my passion for healthcare policy and advocating for

the health promotion of those in my community and nationwide. In my first year I

addressed a policy brief to the American Nursing Association regarding the

implementation of a mental health screening change that could aid in decreasing the

homeless veteran population and vulnerable military members. I also addressed the

American College of Obstetricians and Gynecologists on furthering the education of

primary care providers relating to breastfeeding. I became a member of a national nurse

practitioner organization. Through this organization I have become more aware of the

issues that are affecting nurse practitioners across the country. During my EBP project, I

collaborated with the nursing leadership to engage the community in breastfeeding

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promotion. I feel I have been well prepared to make a difference in healthcare policy in

my future practice.

DNP Essential VI: Interprofessional Collaboration for Improving Patient &

Population Health Outcomes

Objective 1: Demonstrate advanced levels of clinical practice within defined

ethical, legal, and regulatory parameters in designing, implementing, and evaluating

evidenced-based, culturally competent therapeutic interventions for individuals or

aggregates.

Objective 3: Demonstrate leadership in collaborative efforts to develop and

implement policies to improve health care delivery and outcomes at all levels of

professional practice.

The DNP program prepared me to be an effective team leader for today’s

complex and multitiered healthcare environment. My education has prepared me to work

collaborate with highly skilled individuals from multiple professions to provide the

highest patient care. I have advanced preparation which will enable me to facilitate

collaborative team functioning. Throughout the program I created business proposals and

developed executive summaries. Through my DNP project I shared evidence-based

literature with clinicals in the hospital setting, proposed new guidelines and effectively

implemented change. The guideline I created for my DNP project was implemented and

it has been suggested that then guideline will be implemented throughout the hospital

system. I plan to disseminate the results of my project both locally and nationwide.

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DNP Essential VII: Clinical Prevention & Population Health for Improving

Nation’s Health

Objective 6: Employ a population health focus in the design, implementation,

and evaluation of health care delivery systems that address primary, secondary, and

tertiary levels of prevention.

The DNP program is based on the foundation of health promotion and disease

prevention. This foundation will enable me to analyze epidemiological, biostatical,

occupational, and environmental data in the development, implementation, and

evaluation of patient and population-based health promotion and prevention. Through my

DNP project I addressed low breastfeeding rates and how this directly related to illness

and disease progression. I created a guideline to aid in addressing and overcoming

common breastfeeding barriers experiencing. At the beginning of my program, I

addressed veteran mental health disparities and wrote policy brief to the American

Nursing Association. In the clinical setting utilized The PHQ9, ASCVD risk assessment,

the confusion assessment tool, the Mini Cog, the generalized anxiety disorder scale and

many others in the assessment and prevention of health disorders. I am confident in my

ability to apply this foundation of clinical prevention and promotion as an advanced

practice provider.

DNP Essential VIII: Advanced Nursing Practice

Objective 1: Demonstrate advanced levels of clinical practice within defined

ethical, legal, regulatory parameters in designing, implementing, and evaluating

evidence-based, culturally competent therapeutic interventions for individuals or

aggregates.

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The 3 years of DNP school have results in the personal and academic growth.

Throughout the program evidence-based practice has been the focus and I have been able

to demonstrate my use of evidence-based practice through my clinical rotations. I have

demonstrated the ability to utilize evidence-based resources such as UpToDate, Ortho

Bullets, Epocrates, lactmed, Center for Disease Control and Prevention, American

Academy of Pediatrics, American College of Obstetricians and Gynecologists and many

more. I am confident in the knowledge I attained throughout my DNP program. I am

prepared to start my new role as a novice NP and further grow into the best NP I can be.

telehealth breastfeeding: best practice guideline

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